Dispelling misconceptions about who uses e‐cigarettes and why

E‐cigarettes are not predominantly used as smoking cessation tools for older smokers

In Australia, the use of e‐cigarettes has increased substantially in recent years, especially among adolescents and young adults,1 despite our unique and somewhat complex approach to regulating the devices and their e‐liquids.2 It is now well established that e‐cigarettes pose a threat to public health.3 A recent umbrella review found that e‐cigarette users are at least three times as likely to start smoking cigarettes than non‐users, and that former smokers using e‐cigarettes are twice as likely to relapse to cigarette smoking.4 However, a key premise of e‐cigarette proponents is that they are effective smoking cessation and harm reduction tools, intended to help smokers attempting to quit or reduce tobacco use rather than to recruit new nicotine users.

In this issue of the MJA, Freeman and colleagues5 invalidate the notion that e‐cigarettes are predominantly for older smokers who have struggled to quit using approved methods. The authors have made use of an extremely valuable resource for determining trends in e‐cigarette use in New South Wales: the Cancer Institute NSW Tobacco Tracking Survey (CITTS). Key attributes of the CITTS are its ongoing survey design (weekly interviews since 2005) and its involvement of more than 10000 participants who are either current smokers or have recently quit smoking.

A critical finding of the study was a more than threefold increase in e‐cigarette use among young adult smokers or recent smokers (under 24 years of age) between 2016 and 2020, alongside a small decline among people aged 55 years or older.5 This finding runs counter to e‐cigarette proponent claims that the products are primarily tobacco harm reduction tools and targeted at older adults who want to quit smoking. Further, young adults report that they mainly use e‐cigarettes for “taste” and “entertainment” rather than to replace cigarettes,6 and in Australia they are misinformed about the efficacy of e‐cigarettes as smoking cessation and harm reduction tools.7

Another important outcome reported by Freeman and colleagues5 were the reasons users reported for using e‐cigarettes, categorised by age and cigarette smoking status. The most frequent reasons across all age groups were “to help me quit cigarettes” and “to cut down on the number of cigarettes I smoke” (one‐quarter to one‐third of respondents in each age group). This is consistent with other research8 and findings of the National Drug Strategy Household Survey.1 However, more than two‐thirds of current smokers also using e‐cigarettes were not using them for these purposes; in particular, only 21% of young adults (18–24 years) stated they used e‐cigarettes to help them quit smoking, while 27% did so because they preferred the taste of e‐cigarettes to tobacco cigarettes. Only 41% of recent quitters stated they had used e‐cigarettes to help quit smoking, indicating that 59% did not. Unfortunately, the survey design did not permit determination of the proportion of recent quitters who successfully quit using e‐cigarettes alone, nor whether they have continued to use e‐cigarettes.

The report by Freeman and her colleagues5 was based on interviews during 2016–2020, a period during which e‐cigarette technologies evolved considerably and significant regulations were legislated in NSW, including bans on advertising and bans on their use in smoke‐free areas. Despite increased restrictions, in NSW “the proportions of surveyed smokers and recent quitters using e‐cigarettes increased from 2016 to 2018, and had not markedly declined by 2020”, particularly among people aged 18–24 years.5 This suggests that such actions have had limited impact on e‐cigarette uptake, and that additional measures are required. Two initiatives have been instigated since 2020: the NSW Health‐led Facts about vaping initiative9 and the Therapeutic Goods Administration Therapeutic Goods (Standard for Nicotine Vaping Products) Order (TGO110).10 Facts about vaping comprises evidence‐based resources aimed at increasing “awareness around vapes and the health risks of vaping” and addressing “the myths and misperceptions about vaping”,11 while TGO110 outlines quality and safety requirements for e‐liquids in Australia. These initiatives came into effect after the period covered by the study of Freeman and colleagues5, and it will be interesting to see what effects they have on vaping rates, as reflected in future CITTS interviews.